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The aim of this systemic review and meta-analysis was to examine the differences in caesarean section rates across European regions and at a country level by utilizing the Robson classification system. The study has compared caesarean rates across European regions using the Robson classification to identify the drivers of caesarean section use. This review shows significant variations in caesarean section rates across European regions, ranging from 16.9 % in Northern Europe to 43.6 % in Southern Europe. There was a higher contribution of previous CS (Robson Group 5), ranging from 51.2 to 95.0 % of CS in this group to overall rates, particularly in Southern Europe (95.0 %), raises concerns about the "domino effect" of primary caesareans. This finding emphasises the critical importance of strategies to reduce primary CS rates., Background: Caesarean section (CS) rates exhibit considerable global variation, reflecting diverse medical practices, cultural attitudes, and healthcare policies. While some regions maintain relatively low rates, others report significantly higher incidences of the procedure. Analysing these differences is crucial for understanding and developing targeted healthcare strategies and ensuring optimal maternal and neonatal outcomes. This review examines differences in CS rates in Europe according to the Robson 10 group classification., Methods: We identified articles between January 2000 to June 2023 using MEDLINE/PubMed, CINAHL, EMBASE, Global Index Medicus, Web of Science and Cochrane library. There was no restriction on patient population, except for birth in a country of the European region. We excluded all studies that were conference proceedings and studies reported in a language other than English and Swedish., Findings: The search generated a total of 1024 studies, out of which 44 were included, encompassing 6,641,615 births. The majority were from Northern (38 %) and Western Europe (33.5 %). CS rates varied markedly across Europe, ranging from 16.9 % in Northern region to 43.6 % in Southern Europe. The highest contribution to CS rates came from Robson Group 5 (previous CS), with contributions ranging from 51.2 % in Northern to 95.0 % in Southern Europe. The mode of birth for Robson Group 6 (nulliparous, breech) was predominately by CS (88.8 % in Northern to 92.5 % in Central-Eastern Europe)., Interpretation: CS rates continue to vary widely across Europe, with the highest rates in Southern and the lowest in Northern Europe. Previous CS and breech presentation were prominent drivers of CS rates. Region-specific strategies are needed to address these diverse factors to minimise accelerating CS rates across Europe., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: The World Health Organization recommends a cesarean delivery rate of 5-15%, which is thought to be within the range that can reduce infant morbidity and mortality. Various investigations have shown that those poor newborn outcomes are influenced by a variety of maternal and fetal factors and are more prevalent in emergencies than planned cesarean deliveries. Ethiopia is one of the five nations that account for 50% of all neonatal fatalities worldwide. Sub-Saharan African countries account for 38% of all infant deaths worldwide., Aim: To know the determinants of adverse early neonatal outcomes after emergency cesarean delivery., Method and Material: A multicenter case-control study design would be carried out between November 2022 and January 2023. Using the consecutive method, a sample of 318 mother-newborn pairs was studied. Direct observation and face-to-face interviews were undertaken to gather the data using a semi-structured questionnaire. For both data input and analysis, Epi Data version 4.6 and Stata version 14 software were used. Both the crude and adjusted odds ratios were computed. The measure of significance was based on the adjusted odds ratio with a 95% confidence interval and a p-value of less than 0.05., Results: Maternal age over 35, the presence of danger signs during pregnancy, and non-reassuring fetal heart rate were significantly associated with increased risk of adverse fetal outcomes following emergency cesarean section. Women aged over 35 were 3.6 times more likely to experience adverse fetal outcomes compared to younger women (AOR: 3.6, 95% CI: 1.1, 9.7). Women with danger signs during pregnancy were 3.5 times more likely to have adverse fetal outcomes compared to those without (AOR = 3.5, 95% CI: 2.4, 36). Similarly, cases with non-reassuring fetal heart rate were associated with a 5.2 times higher risk of adverse newborn outcomes (AOR = 5.2, 95% CI: 1.1, 26)., Conclusion: This study identified advanced maternal age (over 35 years old), pregnancy complications, and non-reassuring fetal heart rate as significant risk factors for adverse neonatal outcomes following emergency cesarean section., Competing Interests: Declarations. Ethical approval and consent to participants: All method was conducted according the ethical standards of the declaration Helsinki. The study was conducted under the Ethiopian Health Research Ethics Guidelines. Ethical clearance was obtained from the University of Gondar’s Ethical Review Committee with Ref-MIDW/30/2015 E.C. A formal letter of administrative and case team manager approval was obtained from the three hospitals. Informed consent was taken from each of the study participants. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Twin pregnancy is associated with higher risks of adverse perinatal outcomes for both the mother and the babies. Among the many challenges in the follow-up of twin pregnancies, the mode of delivery is the last but not the least decision to be made, with the main influencing factors being amnionicity and fetal presentation. The aim of the study was to compare perinatal outcomes in two European centers using different protocols for twin birth in case of non-cephalic second twin; the Italian patients being delivered mainly by cesarean section with those in Belgium being routinely offered the choice of vaginal delivery (VD)., Methods: This was a dual center international retrospective observational study. The population included 843 women with a twin pregnancy ≥ 32 weeks (dichorionic or monochorionic diamniotic pregnancies) and a known pregnancy outcome. The population was stratified according to chorionicity. Demographic and pregnancy data were reported per pregnancy, whereas neonatal outcomes were reported per fetus. We used multiple logistic regression models to adjust for possible confounding variables and to compute the adjusted odds ratio (adjOR) for each maternal or neonatal outcome., Results: The observed rate of cesarean delivery was significantly higher in the Italian cohort: 85% for dichorionic pregnancies and 94.4% for the monochorionic vs 45.2% and 54.4% respectively in the Belgian center ( p -value < 0.001). We found that Belgian cohort showed significantly higher rates of NICU admission, respiratory distress at birth and Apgar score of < 7 after 5 min. Despite these differences, the composite severe adverse outcome was similar between the two groups., Conclusion: In this study, neither the presentation of the second twin nor the chorionicity affected maternal and severe neonatal outcomes, regardless of the mode of delivery in two tertiary care centers, but VD was associated to a poorer short-term neonatal outcome.

Background: Placenta accreta spectrum disorders are associated with a high risk of maternal morbidity, particularly when surgery is performed under emergency conditions. This study aimed to investigate the incidence of emergency cesarean delivery in patients with a high probability of placenta accreta spectrum disorders on prenatal imaging and to compare the maternal and neonatal outcomes between patients requiring emergency cesarean delivery and those not requiring emergency cesarean delivery., Data Sources: MEDLINE, Embase, Cochrane, and ClinicalTrials.gov databases were searched., Study Eligibility Criteria: This study included case-control studies reporting the outcomes of pregnancies with a high probability of placenta accreta spectrum on prenatal imaging confirmed at birth delivered via unplanned emergency cesarean delivery vs those delivered via planned elective cesarean delivery for maternal or fetal indications. The outcomes observed were the occurrence of emergency cesarean delivery; incidence of placenta accreta and placenta increta/placenta percreta; preterm birth at <34 weeks of gestation; and indications for emergency delivery. This study analyzed and compared the outcomes between patients who underwent emergency cesarean delivery and those who underwent elective cesarean delivery, including estimated blood loss; number of packed red blood cell units transfused and blood products transfused; transfusion of more than 4 units of packed red blood cell; ureteral, bladder, or bowel injury; disseminated intravascular coagulation; relaparotomy after the primary surgery; maternal infection or fever; wound infection; vesicouterine or vesicovaginal fistula; admission to the neonatal intensive care unit; maternal death; composite neonatal morbidity; fetal or neonatal loss; Apgar score of <7 at 5 minutes; and neonatal birthweight., Methods: Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale for case-control and cohort studies. Random-effect meta-analyses of proportions, risks, and mean differences were used to combine the data., Results: A total of 11 studies with 1290 pregnancies complicated by placenta accreta spectrum were included in the systematic review. Emergency cesarean delivery was reported in 36.2% of pregnancies (95% confidence interval, 28.1-44.9) with placenta accreta spectrum at birth, of which 80.3% of cases (95% confidence interval, 36.5-100.0) occurred before 34 weeks of gestation. The main indication for emergency cesarean delivery was antepartum bleeding, which complicated 61.8% of the cases (95% confidence interval, 32.1-87.4). Patients who underwent emergent cesarean delivery had higher estimated blood loss during surgery (pooled mean difference, 595 mL; 95% confidence interval, 116.10-1073.90; P<.001), higher number of packed red blood cells transfused (pooled mean difference, 2.3 units; 95% confidence interval, 0.99-3.60; P<.001), and higher number of blood products transfused (pooled mean difference, 3.0; 95% confidence interval, 1.10-4.90; P=.002) than patients who underwent scheduled cesarean delivery. Patients who underwent emergency cesarean delivery had a higher risk of requiring transfusion of more than 4 units of packed red blood cell (odds ratio, 3.8; 95% confidence interval, 1.7-4.9; P=.002), bladder injury (odds ratio, 2.1; 95% confidence interval, 1.1-4.0; P=.003), disseminated intravascular coagulation (odds ratio, 6.1; 95% confidence interval, 3.1-13.1; P<.001), and admission to the intensive care unit (odds ratio, 2.1; 95% confidence interval, 1.4-3.3; P<.001). Newborns delivered via emergency cesarean delivery had a higher risk of adverse composite neonatal outcomes (odds ratio, 2.6; 95% confidence interval, 1.4-4.7; P=.019), admission to the neonatal intensive care unit (odds ratio, 2.5; 95% confidence interval, 1.1-5.6; P=.029), Apgar score of <7 at 5 minutes (odds ratio, 2.7; 95% confidence interval, 1.5-4.9; P=.002), and fetal or neonatal loss (odds ratio, 8.2; 95% confidence interval, 2.5-27.4; P<.001)., Conclusion: Emergency cesarean delivery complicates approximately 35% of pregnancies affected by placenta accreta spectrum disorders and is associated with a higher risk of adverse maternal and neonatal outcomes. Large prospective studies are needed to evaluate the clinical and imaging signs that can identify patients with a high probability of placenta accreta spectrum at birth, patients at risk of requiring emergency cesarean delivery or peripartum hysterectomy, and patients at high risk of experiencing intrapartum hemorrhage., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: This study aimed to compare plasma concentrations of anesthetic drugs administered during Cesarean section with low Apgar score in neonates deliveried under general anesthesia and analyze associated risk factors., Methods: Data from 76 neonates undergoing Cesarean section under general anesthesia with blood concentrations of anesthetic drugs were analyzed. A low Apgar score was defined as ≤ 7. Perioperative maternal and neonatal data were collected and analyzed. Neonates were divided into a control group (Group CON, n = 65) and a low Apgar score group (Group LAS, n = 11) based on Apgar score., Results: There were no significant differences in the plasma concentrations of anesthetic drugs in maternal artery, umbilical vein or umbilical artery blood between the two groups. Risk factors for neonatal low Apgar scores during Cesarean section under general anesthesia were premature delivery (aOR 10.2, 95% CI = 1.8-56.9) and preoperative fetal distress (aOR 9.6, 95% CI = 1.3-69.0). The prediction model was: probability = 1/(e ‑Y ), Y= -4.607 + 2.318× (premature delivery) + 2.261× (fetal distress) (yes = 1, no = 0). The Hosmer-Lemeshow test showed χ²= 9.587, P = 0.213, and the area under the curve (AUC) was 0.850 (0.670 ~ 1.000). With a cutoff value of 0.695, sensitivity and specificity were 81.8% and 87.7%, respectively., Conclusions: There was no correlation between blood concentration of general anesthetic drugs and Apgar score or occurrence of neonatal low Apgar scores. Premature delivery and preoperative fetal distress were identified as independent risk factors for neonatal low Apgar scores after Cesarean section under general anesthesia., (© 2024. The Author(s).)

Purpose: Pregnancies complicated by placenta accreta spectrum (PAS) are associated with severe maternal morbidities. The aim of this study is to describe the neonatal outcomes in pregnancies complicated with PAS compared with pregnancies not complicated by PAS., Methods: A retrospective cohort study conducted at a single tertiary center between 03/2011 and 01/2022, comparing women with PAS who underwent cesarean delivery (CD) to a matched control group of women without PAS who underwent CD. We evaluated the following adverse neonatal outcomes: umbilical artery pH < 7.0, umbilical artery base excess ≤ - 12, APGAR score < 7 at 5 min, neonatal intensive care unit (NICU) admission, mechanical ventilation, hypoxic ischemic encephalopathy, seizures and neonatal death. We also evaluated a composite adverse neonatal outcome, defined as the occurrence of at least one of the adverse neonatal outcomes described above. Multivariable regression analysis was used to determine which adverse neonatal outcome were independently associated with the presence of PAS., Results: 265 women with PAS were included in the study group and were matched to 1382 controls. In the PAS group compared with controls, the rate of composite adverse neonatal outcomes was significantly higher (33.6% vs. 18.7%, respectively, p < 0.001). In a multivariable logistic regression analysis, Apgar score < 7 at 5 min, NICU admission and composite adverse neonatal outcome were independently associated with PAS., Conclusion: Neonates in PAS pregnancies had higher rates of adverse outcomes. Apgar score < 7 at 5 min, NICU admission and composite adverse neonatal outcome were independently associated with PAS., (© 2024. The Author(s).)

Background: Placenta accreta spectrum disorders (PASDs) increase the mortality rate for mothers and newborns over a decade. Thus, the purpose of the study is to evaluate the neonatal outcomes in emergency cesarean section (CS) and planned surgery as well as in Cesarean hysterectomy and the modified one-step conservative uterine surgery (MOSCUS). The secondary aim is to reveal the factors relating to poor neonatal outcomes., Methods: This was a single-center retrospective study conducted between 2019 and 2020 at Tu Du Hospital, in the southern region of Vietnam. A total of 497 pregnant women involved in PASDs beyond 28 weeks of gestation were enrolled. The clinical outcomes concerning gestational age, birth weight, APGAR score, neonatal intervention, neonatal intensive care unit (NICU) admission, and NICU length of stay (LOS) were compared between emergency and planned surgery, between the Cesarean hysterectomy and the MOSCUS. The univariate and multivariable logistic regression were used to assess the adverse neonatal outcomes., Results: Among 468 intraoperatively diagnosed PASD cases who underwent CS under general anesthesia, neonatal outcomes in the emergency CS (n = 65) were significantly poorer than in planned delivery (n = 403). Emergency CS increased the odds ratio (OR) for earlier gestational age, lower birthweight, lower APGAR score at 5 min, higher rate of neonatal intervention, NICU admission, and longer NICU LOS ≥ 7 days with OR, 95% confidence interval (CI) were 10.743 (5.675-20.338), 3.823 (2.197-6.651), 5.215 (2.277-11.942), 2.256 (1.318-3.861), 2.177 (1.262-3.756), 3.613 (2.052-6.363), and 2.298 (1.140-4.630), respectively, p < 0.05. Conversely, there was no statistically significant difference between the neonatal outcomes in Cesarean hysterectomy (n = 79) and the MOSCUS method (n = 217). Using the multivariable logistic regression, factors independently associated with the 5-min-APGAR score of less than 7 points were time duration from the skin incision to fetal delivery (min) and gestational age (week). One minute-decreased time duration from skin incision to fetal delivery contributed to reduce the risk of adverse neonatal outcome by 2.2% with adjusted OR, 95% CI: 0.978 (0.962-0.993), p = 0.006. Meanwhile, one week-decreased gestational age increased approximately two fold odds of the adverse neonatal outcome with adjusted OR, 95% CI: 1.983 (1.600-2.456), p < 0.0001., Conclusions: Among pregnancies with PASDs, the neonatal outcomes are worse in the emergency group compared to planned group of cesarean section. Additionally, the neonatal comorbidities in the conservative surgery using the MOSCUS method are similar to Cesarean hysterectomy. Time duration from the skin incision to fetal delivery and gestational age may be considered in PASD surgery. Further data is required to strengthen these findings., (© 2024. The Author(s).)

Objective: To compare the labor duration and other maternal and neonatal outcomes between hospitalized women with uncomplicated pregnancies receiving amniotomy at 5 cm cervical dilatation and those not receiving amniotomy., Methods: This prospective, randomized controlled trial was conducted at a tertiary hospital between June 2020 and October 2021. The study included low-risk pregnant women with spontaneous onset of labor at term, carrying a single fetus in cephalic presentation and with intact amniotic membranes. When the cervical dilatation reached 5 cm, participants were randomly assigned to receive or not receive amniotomy. Maternal demographics, labor and delivery data, and neonatal outcomes were compared between the two groups., Results: The amniotomy group had a significantly shorter duration of labor compared with the control group (mean difference 49.4 min, 95% confidence interval [CI] 16.8-81.9, P = 0.003). The following outcomes were not significantly different between the two groups: (1) the need for oxytocin to augment labor; (2) cesarean section rates; (3) the incidence rates of suspected fetal distress and instrumental delivery; and (4) neonatal outcomes., Conclusions: Compared with expectant management, amniotomy during the active phase of labor (as newly defined by WHO) can shorten the labor duration without an increased risk of cesarean delivery or other negative consequences. THAI CLINICAL TRIALS REGISTRY (TCTR) (TCTR20200522001): https://www.thaiclinicaltrials.org/show/TCTR20200522001., (© 2024 International Federation of Gynecology and Obstetrics.)

Introduction: The trends of increasing use of cesarean section (CS) with a decrease in assisted vaginal birth (vacuum extraction or forceps) is a major concern in health care systems all over the world, particularly in low-resource settings. Studies show that a first birth by CS is associated with an increased risk of repeat CS in subsequent births. In addition, CS compared to assisted vaginal birth (AVB), attracts higher health service costs. Resource-constrained countries have low rates of AVB compared to high-income countries. The aim of this study was to compare mode of birth in the subsequent pregnancy among women who previously gave birth by vacuum extraction or second stage CS in their first pregnancy at Mulago National Referral Hospital, Uganda., Methods: This was a retrospective cohort study that involved interviews of 81 mothers who had a vacuum extraction or second stage CS in their first pregnancy at Mulago hospital between November 2014 to July 2015. Mode of birth in the subsequent pregnancy was compared using Chi-2 square test and a Fisher's exact test with a 0.05 level of statistical significance., Results: Higher rates of vaginal birth were achieved among women who had a vacuum extraction (78.4%) compared to those who had a second stage CS in their first pregnancy (38.6%), p < 0.001., Conclusions and Recommendations: Vacuum extraction increases a woman's chance of having a subsequent spontaneous vaginal birth compared to second stage CS. Health professionals need to continue to offer choice of vacuum extraction in the second stage of labor among laboring women that fulfill its indication. This will help curb the up-surging rates of CS., (© 2024. The Author(s).)

Purpose: As a Doppler sonographic parameter, the cerebroplacental ratio (CPR) provides information about fetal hemodynamics and the redistribution of fetal blood volume in response to a metabolic change. The present study was undertaken to determine the extent to which CPR can be used as a valid parameter in routine obstetric assessment. We investigated whether CPR can be used to assess the neonatal outcome in appropriate for gestational age (AGA) fetuses and its association with secondary cesarean section due to fetal distress., Methods: In this retrospective analysis 1739 pregnant women were admitted to the University Women's Clinic Magdeburg, Germany, between January 2016 and December 2017. Of them, 710 AGA fetuses were eligible for analysis. SGA fetuses with an estimated fetal weight < 10th percentile were excluded from the study. The AGA fetuses were divided in two groups based on the CPR: 669 fetuses showed a normal CPR ≥ 1.08; 41 fetuses showed a decreased CPR < 1.08., Results: In our study cohort decreased CPR in AGA fetuses was associated with threefold increased rate of cesarean sections due to fetal distress (p < 0.001). Our data suggested that low CPR is a reliable predictor of an impaired neonatal outcome in AGA fetuses in terms of a lower birth weight, transfer to neonatology, longer length of hospitalization, and the presence of severe morbidity., Conclusion: Decreased CPR in AGA fetuses correlated with impaired neonatal outcome and secondary cesarean section due to fetal distress. The potential role of CPR for obstetric screening should be investigated in further studies., (© 2022. The Author(s).)

Objective: We aimed to investigate the association of advanced maternal age with intrapartum cesarean delivery and to assess its risk factors and perinatal outcomes., Study Design: A retrospective cohort study of all women with singleton pregnancies who attempted a trial of labor (≥24 + 0 weeks of gestation) in a single center (2011-2017). The study population was stratified by parity (nulliparous or multiparous) and further sub-categorized into three cohorts: (1) women <35 years at birth (reference group), (2) women aged 35-40 years, and (3) women >40 years. Labor and delivery characteristics and neonatal outcomes were compared., Results: Overall, 55,089 women were included: 39, 192 (71.1%) were under 35 years old, 15,90712,892 (28.923.4%) were 35-40 y and 3,015 (5.5%) were >40 y. For nulliparas, the rate of intrapartum Cesarean deliveries increased with maternal age and approached 25.3% in those >40 y as compared to 8.9% for those <35 y. The positive association between Cesarean section rates and maternal age extends beyond nulliparas and is also seen in multiparas, although to a smaller degree. After adjusting for confounders, maternal age was significantly and independently associated with intrapartum cesarean delivery in a dose-dependent manner in nulliparous women, [adjusted Odd Ratio (aOR) 1.56 (95% Confidence Interval (CI) 1.39-1.76) and 2.53 (2.07-3.09)] among women aged 35-40 y and >40 y, respectively. Maternal age was not significantly associated with adverse neonatal outcome., Conclusion: Advanced maternal age is an independent risk factor for intrapartum Cesarean delivery. Yet, the majority of older gravidae who attempt a trial of labor, even if nulliparous, deliver vaginally without an increase in adverse neonatal outcome.

Objectives: To compare short term variation (STV) and phase rectified signal averaging (PRSA) and their association with fetal outcome in early onset fetal growth restriction (FGR)., Methods: Data were used from a retrospective cohort study of women who were admitted for FGR and/or pre-eclampsia and who were delivered by pre-labor Cesarean section or had a fetal death before 32 weeks' gestation. Computerized cardiotocography (cCTG) registrations of the 5 days before delivery or fetal death were used for calculation of STV and PRSA. PRSA was expressed as the average acceleration capacity (AAC) and average deceleration capacity (ADC). FHR decelerations were classified visually as absent, 1-2 per hour or recurrent. Abnormality of STV and of PRSA was either analyzed as a single parameter or in combination with recurrent decelerations. Endpoints were defined as composite adverse condition at birth consisting of fetal death, low Apgar score, low umbilical pH, the need for resuscitation after birth and as major neonatal morbidity or neonatal death., Results: Included were 367 pregnancies of which 20 resulted in fetal death. An abnormal cCTG with either recurrent decelerations and/or low STV or recurrent decelerations and/or low PRSA were similarly associated with composite adverse condition at birth (n=99), but neither with major neonatal morbidity., Conclusions: PRSA and STV have similar efficacy for measuring fetal heart rate variation in early onset FGR. An increased risk of a composite adverse condition at birth is indicated by a low value of either parameter and/or the presence of recurrent decelerations., (© 2022 the author(s), published by De Gruyter, Berlin/Boston.)

Objective: To study induction of labor (IOL) at 39 weeks compared with expectant management among women undergoing labor after cesarean section (LAC) with no prior vaginal delivery., Methods: A retrospective cohort study including all women undergoing LAC with no prior vaginal delivery, between March 2011 and January 2021. We allocated the study cohort into two groups: IOL at 39 0/7 to 39 6/7 and all LACs at ≥40 0/7 weeks of gestation. The primary outcome was a composite of adverse neonatal outcome. The secondary outcome was a composite of adverse maternal outcome., Results: Overall, 1022 women met inclusion criteria, of whom 89 (8.7%) had IOL at 39 0/7 -39 6/7 weeks and 933 (91.3%) had LAC at ≥40 0/7 weeks. The composite neonatal outcome rate was comparable between groups (0.186). There were three uterine ruptures (3.4%) in the IOL group and 11 (1.2%) in the LAC at ≥40 weeks group (P = 0.115). The rate of the composite maternal outcomes occurrence was higher in the IOL group (18.0% vs. 10.1%, P = 0.022)., Conclusion: IOL at 39 weeks among women undergoing LAC with no prior vaginal delivery is not associated with improved neonatal outcomes when compared with expectant management but may be associated with a higher rate of adverse maternal outcomes., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Objective: To characterize pregnancies in which meconium-stained amniotic fluid (MSAF) was incidentally discovered during elective caesarean delivery (CD), and to evaluate the association with adverse neonatal outcomes., Methods: A retrospective study was performed on all patients who underwent elective CD with singleton pregnancies between March 2011 and June 2020. Data analyzed included maternal, pregnancy, and neonatal characteristics. A comparison was made between pregnancies with clear amniotic fluid, MSAF, and thick MSAF., Results: During the study period, 10 445 patients with singleton pregnancies underwent elective CD. Of them, 368 (3.5%) had MSAF and 31 (0.3%) had thick MSAF. Patients with MSAF gained more weight during pregnancy and suffered more from diabetes compared with patients with clear fluid. Significantly more pregnancies with MSAF had either oligohydramnios or polyhydramnios. Pregnancies in the thick-MSAF group had more intrahepatic cholestasis of pregnancy. No differences were found between the groups in the composite adverse neonatal outcome, including 5-min Apgar score, need for mechanical ventilation, and admission to the neonatal intensive care unit., Conclusion: The incidental finding of MSAF during elective CD is not associated with increased risks of adverse neonatal outcomes., (© 2021 International Federation of Gynecology and Obstetrics.)

Objective: To determine maternal and neonatal complications associated with an intrapartum cesarean delivery (CD) with and without a history of a previous CD., Methods: A retrospective cohort study of all women who underwent an unplanned intrapartum CD following a trial of labor in a university-affiliated tertiary hospital, between 2009 and 2016. Perinatal outcomes of women with and without a history of a previous CD were compared. Composite adverse maternal outcome included one or more of the following: postpartum hemorrhage, need for blood transfusion, or cesarean hysterectomy. Composite adverse neonatal outcome included one or more of the following: 5-min Apgar score <7, neonatal seizure, need for intubation, meconium-aspiration-syndrome, or hypoxic-ischemic encephalopathy., Results: During the study period, 42 275 women attempted vaginal delivery. Of them, 2229 (5.3%) women underwent an unplanned intrapartum CD and met inclusion criteria: 337 (15.1%) with (study group) and 1892 (84.9%) without (control group) a previous CD. Women without a previous CD were younger and were characterized by higher rates of nulliparity and induction of labor compared with women with a previous CD. Other demographic and obstetrical characteristics did not differ between the groups. Indications for CD were also comparable between the groups. Uterine rupture complicated 2.3% of trials of labor among women with a previous CD. Adverse maternal (2.7% vs 2.9%, P = 1.0) and neonatal (3.9% vs 4.3%, P = 0.88) outcomes were comparable between the groups. After adjusting for potential confounders, a previous CD was not associated independently with adverse maternal outcomes (adjusted odds ratio [aOR] 0.86, 95% confidence interval [CI] 0.31-2.38; P = 0.78) or neonatal outcomes (aOR 0.79, 95% CI 0.36-1.75; P = 0.56)., Conclusion: Our study provides evidence that perinatal outcomes of intrapartum CD delivery among women with a previous CD do not differ from those in women without a previous CD. These findings might improve the consultation and informed decision-making process for couples considering a trial of labor after CD., (© 2021 International Federation of Gynecology and Obstetrics.)

Objectives: Cesarean section is the most common obstetric surgical procedure, with associated risks for adverse neonatal outcomes. The interplay of perinatal factors associated with neonatal admissions following cesarean delivery remains poorly understood in developing countries. We examined how perinatal and facility-based factors affect Neonatal Intensive Care Unit (NICU) admission after cesarean delivery in northern Nigeria., Methods: A prospective cohort study involving 200 women undergoing cesarean section were consecutively enrolled with subsequent follow-up of their infants in the post-natal period. Data were abstracted from the medical record using an interviewer-administered questionnaire. The primary outcomes were NICU admission and intrauterine or early neonatal deaths. Binary logistic regression modelling was used to identify variables independently associated with the outcomes., Results: Over the study period (six months), there were 200 cesarean sections. A total of 30 (15.0%) neonates were admitted into the NICU following the procedure. No stillbirths or early neonatal deaths were recorded. NICU admission was associated with gestational age (preterm vs. term [adjusted odds ratio, aOR: 18.9, 95% confidence interval (CI): 4.0-90.4]), birth weight (small vs. appropriate [aOR: 6.7, 95% CI 1.9-22.7] and large vs. appropriate birth weight [aOR: 20.3, 95% CI 2.9-143.7]) and the number of indications for cesarean section (≥2 vs. one [aOR: 0.2, 95% 0.1-0.8])., Conclusions: Prematurity, small and large for gestational age neonates; and indications for cesarean section were associated with increased likelihood of neonatal admission following cesarean delivery. These findings could inform ongoing quality enhancement initiatives to improve NICU admission outcomes at the study site, and other similar settings., (© 2022 Walter de Gruyter GmbH, Berlin/Boston.)

General anaesthesia is known to achieve the shortest decision-to-delivery interval for category-1 caesarean section. We investigated whether the COVID-19 pandemic affected the decision-to delivery interval and influenced neonatal outcomes in patients who underwent category-1 caesarean section. Records of 562 patients who underwent emergency caesarean section between 1 April 2019 and 1 July 2019 in seven UK hospitals (pre-COVID-19 group) were compared with 577 emergency caesarean sections performed during the same period during the COVID-19 pandemic (1 April 2020-1 July 2020) (post-COVID-19 group). Primary outcome measures were: decision-to-delivery interval; number of caesarean sections achieving decision-to-delivery interval < 30 min; and a composite of adverse neonatal outcomes (Apgar 5-min score < 7, umbilical arterial pH < 7.10, neonatal intensive care unit admission and stillbirth). The use of general anaesthesia decreased significantly between the pre- and post-COVID-19 groups (risk ratio 0.48 (95%CI 0.37-0.62); p < 0.0001). Compared with the pre-COVID-19 group, the post-COVID-19 group had an increase in median (IQR [range]) decision-to-delivery interval (26 (18-32 [4-124]) min vs. 27 (20-33 [3-102]) min; p = 0.043) and a decrease in the number of caesarean sections meeting the decision-to-delivery interval target of < 30 min (374/562 (66.5%) vs. 349/577 (60.5%); p = 0.02). The incidence of adverse neonatal outcomes was similar in the pre- and post-COVID-19 groups (140/568 (24.6%) vs. 140/583 (24.0%), respectively; p = 0.85). The small increase in decision-to-delivery interval observed during the COVID-19 pandemic did not adversely affect neonatal outcomes., (© 2021 Association of Anaesthetists.)

Background: In recent years, higher than the recommended rate of oxytocin use has been observed among low-risk women. This study examines the relationship between oxytocin administration and birth outcomes in women and neonates., Methods: A retrospective analysis of birth and neonatal outcomes for women who received oxytocin versus those who did not. The sample included 322 women with a low-risk pregnancy., Results: Oxytocin administration was associated with cesarean section (aOR 4.81, 95% CI: 1.80-12.81), instrumental birth (aOR 3.34, 95% CI: 1.45-7.67), episiotomy (aOR 3.79, 95% CI: 2.20-6.52) and length of the second stage (aOR 00:18, 95% CI: 00:04-00:31). In neonatal outcomes, oxytocin in labor was associated with umbilical artery pH ≤ 7.20 (OR 3.29, 95% CI: 1.33-8.14). Admission to neonatal intensive care unit (OR 0.56, 95% CI: 0.22-1.42), neonatal resuscitation (OR 1.04, 95% CI: 0.22-1.42), and Apgar score <7 (OR 0.48, 95% CI: 0.17-1.33) were not associated with oxytocin administration during labor., Conclusions: Oxytocin administration during labor for low-risk women may lead to worse birth outcomes with an increased risk of instrumental birth and cesarean, episiotomy and the use of epidural analgesia for pain relief. Neonatal results may be also worse with an increased proportion of neonates displaying an umbilical arterial pH ≤ 7.20.

Objective: To compare neonatal outcomes of women with a body mass index (BMI) of ≥35 kg/m 2 who underwent a trial of labour with those of women who underwent a planned primary caesarean section (CS)., Design: A retrospective cohort study of births between April 2012 and March 2014., Setting: A provincial database: Better Outcomes Registry & Network (BORN) Ontario, Canada., Population: A cohort of 8752 women with a BMI of ≥35 kg/m 2 who had a singleton birth at 38-42 weeks of gestation., Methods: Neonatal outcomes were compared between women who underwent a trial of labour (with either a successful vaginal birth or intrapartum CS) and those who underwent a planned CS., Main Outcome Measure: A composite of any of the following outcomes: intrapartum neonatal death, neonatal intensive care unit admission, 5-minute Apgar score of <7 or umbilical artery pH of <7.1., Results: During the study period, 8433 (96.4%) women had a trial of labour and 319 (3.6%) had a planned CS. Intrapartum CS was performed in 1644 (19.5%) cases. There was no association between planned mode of delivery and the primary outcome (aOR 0.80, 95% CI 0.59-1.07). The primary outcome was lower among women who had a successful trial of labour (aOR 0.67, 95% CI 0.50-0.91) and was higher among women who had a failed trial of labour (aOR 1.74, 95% CI 1.21-2.48), compared with women who underwent a planned CS., Conclusions: In women with a BMI of ≥35 kg/m 2 at a gestational age of 38-42 weeks, neonatal outcomes are comparable between planned vaginal delivery and planned CS, although a failed trial of labour is at risk of adverse neonatal outcome., Tweetable Abstract: Neonatal outcomes are not affected by planned mode of delivery in women who are obese, with a BMI of ≥35 kg/m 2 ., (© 2020 John Wiley & Sons Ltd.)

Introduction: We aimed to underline the determinants of adverse neonatal outcome in gestations complicated by placenta previa (PP)., Methods: A retrospective study including all women diagnosed with placenta previa carrying a singleton gestation who delivered between 2011 and June 2019. Gestations with adverse neonatal outcomes were compared to those without. In a secondary analysis, we further studied the rate of Placenta accreta spectrum (PAS) in relation to number of previous cesarean deliveries., Results: Overall, 548/84,558 (0.6%) singleton deliveries were complicated by PP (0.6%). PAS was noted in 105 (19.2%) cases. After exclusion of PAS cases, adverse neonatal outcome occurred in 149/443 (33.6%), median gestational age of delivery was 37 0/7 with a median birthweight of 2780 g. In a univariate analysis, adverse neonatal outcome was associated with emergent delivery and general anesthesia [56.8% vs. 20.8%, OR 5.00 (95% CI) 3.24-7.72, p < 0.001 and 54.4% vs. 24.8%, OR 3.60 (95% CI) 2.37-5.47, p < 0.001, respectively]. Gestational age at delivery was lower in the adverse outcome group (mean 35 1/7 vs. 37 3/7 , p < 0.001). In a multivariate regression analysis, general anesthesia and gestational age at delivery were independently associated with adverse neonatal outcome [adjusted odds ratio (aOR) 2.26 (95% CI) 1.18-4.31, p = 0.01, aOR 1.10 (95% CI) 1.05-1.16, p < 0.001. Analysis of the rate of PAS among women with previous cesarean delivery and PP revealed that no cases of PAS were noted when no prior cesarean delivery was present. The rate of PAS for previous 1, 2, 3, 4 and 5 cesarean deliveries was 26.7%, 43.5%, 65.5%, 55.6% and 66.7% respectively., Discussion: Efforts should be made to avoid general anesthesia in deliveries of PP., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Introduction: The nine-item list, with organizational and cultural changes, was implemented at the delivery unit in Linköping, Sweden between 2007 and 2010, aiming at improving the quality of care by offering more women a safe and attractive vaginal delivery. The target group for the intervention was nulliparous women at term with spontaneous onset of labor and cephalic presentation (Robson group 1). The aim of this study was to evaluate pregnancy outcomes before, during, early post and late post introduction of the nine-item list., Material and Methods: Robson group 1 births (n = 12 763) from 2004 to 2018 were divided into four time periods; before the nine-item list (2004-2006), during introduction of the nine-item list (2007-2010), early post introduction of the nine-item list (2011-2014) and late post introduction of the nine-item list (2015-2018). The nine-item list consists of monitoring of obstetric results, midwife coordinator, risk classification of women, three midwife-competence levels, teamwork-the midwife, obstetrician and nurse working as a team with the common goal of a normal delivery, obstetric morning round, fetal monitoring skills and obstetric skills training. Perinatal outcomes before, during, early post and late post introduction were compared using a Student's t test for numerical variables and a Pearson chi-squared test for categorical variables., Results: Apgar score <7 at 5 minutes, Apgar score <4 at 5 minutes and umbilical cord arterial pH <7 did not differ significantly between the four time periods. Between before introduction and early post introduction, instrumental vaginal delivery decreased from 19.8% to 12.2% and cesarean section from 9.6% to 4.5%. The late post introduction period showed a maintained effect with 10.7% instrumental deliveries and 3.9% cesarean sections. Obstetric anal sphincter injury grade III decreased instantly during the introduction of the nine-item list from 7.8% to 5.1% and thereafter remained unchanged., Conclusions: Implementation of the nine-item list increased the proportion of spontaneous vaginal deliveries by reducing the number of instrumental deliveries and cesarean sections without affecting the neonatal outcomes in nulliparous women with spontaneous onset of labor. The nine-item list intervention seems to provide long-term sustainable results., (© 2020 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Background/aim: In Germany, performance of an emergency Cesarean section (ECS) is recommended within an interval of ≤20 min from decision to delivery (DDI). The aim of the study was to assess the duration of DDI in ECS as well as its impact on neonatal outcome., Patients and Methods: Data from 437 patients at a single, tertiary care hospital were retrospectively analysed regarding influence on the duration of DDI. Subsequently the impact of DDI on neonatal outcome and incidence of adverse neonatal outcome was analysed., Results: DDI of ECS performed outside core working hours was significantly prolonged (p<0.001). Shorter DDI showed a statistically worse arterial cord blood pH (p=0.001, r=0.162) and base excess (p=0.05; r=0.094). Duration of DDI had no significant impact on the incidence of adverse neonatal outcome (p=0.123)., Conclusion: Awareness of influence on DDI might contribute to expediting DDI, but duration of DDI showed no impact on the incidence of adverse neonatal outcome. Data were not adequate to suggest a recommendation for DDI time standards., (Copyright© 2020, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Aim: We aimed to investigate if the risk of fetal distress during term labor is related to the intrapartum maternal hemoglobin (Hb) level. Second, we investigated the relation between mode of delivery, reason for instrumental delivery and short-term neonatal outcome and maternal Hb. Third, we aimed to identify factors influencing intrapartum maternal Hb level. Methods: A retrospective cohort study was performed in a tertiary hospital in The Netherlands, including data from women who gave birth between 2009 and 2016. To determine whether the likelihood of fetal distress to occur was dependent on intrapartum Hb, multivariate regression models were run with intrapartum Hb as the main independent variable of interest. Hb was used as a continuous value. We repeated this procedure for the likelihood of instrumental vaginal delivery (IVD), cesarean section (CS), 5-min Apgar score < 7, and umbilical cord arterial pH ≤ 7.05 to occur. Also, we identified factors influencing intrapartum Hb level using linear regression analysis. Results: Data of 9144 patients were analyzed. Intrapartum Hb did not contribute to the prediction of the likelihood of fetal distress, IVD for nonprogressive labor, CS for fetal condition, 5-min Apgar score < 7, and pHa ≤ 7.05. However, there was a unique statistically significant contribution of Hb to the prediction of the likelihood of IVD for any reason and IVD for fetal distress and CS for any reason and CS for nonprogressive labor. IVD for fetal distress was related to a higher intrapartum Hb level, whereas CS for nonprogressive labor was related to a lower intrapartum Hb level. Intrapartum Hb level was influenced by maternal age, ethnicity, parity, fetal sex, and birth weight. Conclusions: The risk of fetal distress and adverse neonatal outcome is not related to intrapartum Hb levels. However, our data suggest that mode of delivery is dependent on intrapartum Hb, as shown in a large tertiary population. We recommend further investigating this relation in a large prospective study.

Purpose: Epilepsy is a common neurological disorder that may complicate reproductive health. Our aim in this study was to provide prospective ascertainment of obstetric and neonatal outcomes in women with epilepsy and investigate whether the risk of pregnancy, delivery, and neonatal complications differed between women with epilepsy and women without epilepsy., Methods: Pregnant women with epilepsy and women without epilepsy (control group) were prospectively evaluated during the years 2013-2018. They were regularly followed by a neurologist and obstetrician until the end of pregnancy., Results: Delivery and perinatal outcomes were compared between 112 women diagnosed with epilepsy and 277 women without epilepsy. Epilepsy was a significant risk factor for preterm delivery, cesarean section, fetal hypoxia, and Apgar score ≤ 7 at 5 min in offspring (odds ratio (OR) = 2.83, 95% confidence interval (CI) 1.03-7.76; OR = 5.61, 95% CI 3.44-9.14; OR = 1.81, 95% CI 1.08-3.04; OR = 8.12, 95% CI 4.04-16.35, respectively). Seizures during pregnancy had influence on the preference of cesarean section as a mode of delivery (ОR = 3.39; 95% CI 1.40-8.17). The rate of perinatal hypoxia was significantly higher in children born by cesarean section (ОR = 2.84; 95% CI 1.04-7.76). There was no significant difference between women with epilepsy and controls in malformation rate., Conclusions: Women with epilepsy had an increased risk of pregnancy and delivery complications. Cesarean section was associated with an increased risk of complications in offspring.

Objective: To provide guidelines regarding the benefits and risks for the neonate and the child of planning vaginal delivery versus planning elective cesarean section in case of term breech presentation., Methods: MedLine and Cochrane Library databases search and review of the main foreign guidelines., Results: In case of term breech presentation, planned vaginal delivery might be associated with an increased composite risk of perinatal mortality or occurrence of a combined outcome of serious neonatal morbidity in comparison to elective cesarean section (LE2). In case of planned vaginal delivery of term breech presentation, the risk of perinatal mortality is around 1‰ (LE3). It is potentially less but still exists in case of elective cesarean section (LE2). Risks of neonatal trauma - especially fracture of clavicle and breech hematoma -, Apgar score lower than 7 at 5minutes, and need for neonatal intubation and ventilation, are increased in case of planned vaginal delivery (LE2) and are around 1% (LE3). However, no difference has been demonstrated between planned vaginal and planned cesarean delivery regarding neurodevelopmental outcomes at 2 years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), and adult intellectual performances (LE4)., Conclusions: In case of term breech presentation, risks of severe complications for neonate and child are low in case of planned vaginal delivery or elective cesarean section. Short-term benefit/risk balance for the neonate might favor elective cesarean section but long-term morbidity seems to be similar whatever the delivery route (Professional consensus)., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Objective: Caesarean section (CS) rates have increased worldwide in recent decades. In 2015, the WHO proposed the use of the 10-group Robson classification as a global standard for assessing, monitoring and comparing CS rates both within healthcare facilities over time and between them. The aim of this study was to assess the pattern of CS rates according to the Robson classification and describe maternal and perinatal outcomes by group at the Tosamaganga Hospital in rural Tanzania., Design: Observational retrospective study., Setting: St. John of the Cross Tosamaganga Hospital, a referral centre in rural Tanzania., Participants: 3012 women who gave birth in Tosamaganga Hospital from 1 January to 30 June 2014 and from 1 March to 30 November 2015., Results: The overall CS rate was 35.2%, and about 90% of women admitted for labour were in Robson groups 1 through 5. More than 40% of the CS carried out in the hospital were performed on nulliparous women at term with a single fetus in cephalic presentation (groups 1 and 3), and the most frequent indication for the procedure was previous uterine scar (39.2%). The majority of severe neonatal outcomes were observed in groups 1 (27.7%), 10 (24.5%) and 3 (19.1%)., Conclusion: We recorded a high CS rate in Tosamaganga Hospital, particularly in low-risk patients groups (Robson groups 1 and 3). Our analysis of Robson classification and neonatal outcomes suggests the need to improve labour management at the hospital and to provide timely referrals in order to prevent women from arriving there in critical conditions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Worldwide, the caesarean section (CS) is the most performed type of surgery and numbers are still rising. The gentle CS has become a more common procedure as it allows the parents to experience birth. Early and continuous skin-to-skin contact between the mother and her newborn is pursued. Parents are not separated from their newborns and stay with their child in the operation theatre and recovery room. However, data are limited on the incidence of surgical site infections (SSI) after gentle CS. The aim of our study was to examine the risk of postoperative wound infections after gentle CS. Secondary outcomes included other maternal complications and neonatal outcomes., Study Design: In this multicenter prospective cohort study, all women who underwent an elective gentle CS between January 2015 and January 2017 were eligible. Demographics, per procedural data, maternal complications and neonatal outcomes were collected. The follow-up lasted until six weeks post partum., Results: Of the 243 performed CSs, two (0.8%) SSIs occurred; one superficial and one deep wound infection. One patient (0.4%) was readmitted for treatment of endometritis. In total, 20 (8.2%) maternal complications were identified. Median time to skin-to-skin contact was 3 minutes (IQR 2-4.25) with a median neonatal oxygen saturation 10 minutes after birth of 95% (IQR 92-98). Mean gestational age was 274 ± 4.1 days (39 + 1 weeks) and mean neonatal pH was 7.28 (±SD 0.07). All children had Apgar scores >7 at 5 minutes after birth. Neonatal admission occurred in 19 cases (7.8%) and neonatal readmission in 10 cases (4.1%)., Conclusion: The gentle CS seems to be a safe procedure for both mother and child and is not associated with an increased risk of surgical site infections or direct suboptimal neonatal outcomes. Therefore, more intensive mother-child interaction during CS is allowed., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Aim: To evaluate the technique of internal podalic version for delivery of high floating head during cesarean section as an alternative for other methods for its delivery and its effects on neonatal outcome., Methods: This study used clinical randomized controlled study design. Three groups of patients each group has 50 patients who attended for elective cesarean section and found to have high floating head during operation, Group I: the babies were delivered by internal podalic version. Group II: the babies were delivered by short curved forceps. Group III: the babies were delivered by vacuum. All groups were compared in regard to time required for delivery of baby, fetal condition, maternal complications, fetal complications and postoperative complications., Results: Hundred-and-fifty patients were selected in the course of preparation of elective cesarean section, all had high floating fetal head, and they were randomly distributed into three groups, each group had 50 patients. There was significant relationship for the favor of Group 1 (study group) as regard the time required for the maneuver as calculated from the end of uterine incision till delivery of whole baby, (24.86, 59.48,54.52 s for Group I, Group II, Group III, respectively) with P-value <0.00001*. Also there was significant relationship as regard the intraoperative maternal complications for the favor of Group I with P-value =0.004. While there was an insignificant relationship between the three groups as regard preoperative data, APGAR score, fetal birth weight, postoperative pain and postoperative maternal data. Despite that there was a significant difference as regard the postoperative neonatal complications, with P-value =0.002*, all these complications were minor and did not need long-term treatment., Conclusion: Use of internal podalic version for delivery of high floating head during cesarean section is a safe and rapid technique, with less maternal and neonatal complications., (© 2019 Japan Society of Obstetrics and Gynecology.)

Purpose: To evaluate whether induction of labor (IOL), as compared with expectant management, in gestational diabetes mellitus (GDM) mothers at term (between 37 0/7 and 40 6/7 ), decreases caesarean section (CS) rate and the rate of adverse composite neonatal outcomes., Methods: A retrospective cohort study, of all women with GDM and a singleton gestation who delivered at term in a single, tertiary, university-affiliated medical center (2007-2014). We compared outcomes of women who underwent IOL at each week of gestation between 37 0/7 and 40 6/7  weeks with women who were managed expectantly. The primary outcome was CS rate., Results: Overall, 2472 GDM patients included in the study, of which 880 women had IOL. CS rate was not found to be significantly different between the groups at any gestational age. IOL at 37 weeks was associated with adverse composite neonatal outcome (aOR 2.2, 95% CI 1.4-3.6) and NICU admission (aOR 2.5, 95% CI 1.4-4.4). At 38 weeks, with NICU admission (aOR 2.0, 95% CI 1.4-2.9), and at 39 weeks with fracture of the clavicle. In a sub-analysis of nulliparous women, IOL at 37 weeks had higher odds of NICU admission and adverse composite neonatal outcomes, at 38 weeks with CS and at 39 weeks with fracture of the clavicle., Conclusions: IOL in GDM mothers at term does not reduce CS rate and may be associated with increased CS rate among nulliparous women at 38 weeks. It is also associated with increased risk for adverse composite neonatal outcome or NICU admission when done prior to 39 0/7  weeks.

Aims: The purpose of this international survey was to describe the impact of current practices and techniques of caesarean section on the neonatal Apgar score in the Czech Republic (CZE) and Slovakia (SVK)., Methods: All Czech and Slovak departments that provide obstetric anaesthesia were invited to participate in a one-month (November 2015) prospective study that monitored in details all peripartum anaesthetic practices, delivered by anaesthesiologists. Participating centers recorded all data on-line in the CLADE-IS database (Masaryk University, CZE)., Results and Discussions: We collected data of 10119 women who delivered 10226 newborns. A caesarean section was recorded in 25.1% of deliveries (CZE 23.2%; SVK 30%). General anaesthesia was used for caesarean section in 37.5% of the cases (CZE 40%, SVK 33%). There was no statistically significant difference in the Apgar score lower than 7 in the 1, 5 or 10 min in groups of general and regional anaesthesia for caesarean section, when only elective sections of in-term babies with birth weight over 2500 g were analyzed. We found no statistically significant differences in the Apgar score in newborns of women intubated for caesarean section in rocuronium (n=21; 2.2%) and suxamethonium (n=889; 93%)., Conclusion: We found no difference in neonatal outcomes in groups of general and regional anaesthesia for caesarean section when only out-of-risk newborns were analyzed. The risk factors were identified as follows: an acute caesarean section, preterm babies, birth weight less than 2 500 g, born in perinatological center and multiple pregnancy - second baby., Trial Registration: ClinicalTrials.gov (ID: NCT02380586) https://clinicaltrials.gov/ct2/show/NCT02380586.

Background: Most major societies do not state a specific recommendation against or in favor of routine umbilical cord gas studies sampling., Objective: We aimed to study the correlation between abnormal umbilical cord gas studies (using 5 different definitions) and adverse neonatal outcomes in scheduled nonlaboring term singleton cesarean deliveries., Study Design: The medical charts, surgical records, and neonatal charts of all singleton cesarean deliveries at 37 0/7 -41 6/7 weeks of gestation between January 2009 and May 2018 from a single tertiary center were reviewed. The cohort of singleton cesarean deliveries was divided into those with "normal" vs "abnormal" umbilical cord gas studies with the 5 different definitions: (1) definition A: pH ≤7.15; (2) definition B: pH ≤7.15 and base excess ≤-12 mmol/L; (3) definition C: pH ≤7.1l (4) definition D: pH ≤7.1 and base excess ≤-12 mmol/L, and (5) definition E: pH <7.0 and base excess ≤-12 mmol/L. Adverse neonatal outcomes included Apgar scores at 5 minutes ≤7, neonatal sepsis, blood transfusion, phototherapy, respiratory morbidity (presence of respiratory distress syndrome, transient tachypnea of the newborn infant, mechanical ventilation, need for respiratory support, or meconium aspiration), cerebral morbidity (presence of intraventricular hemorrhage, seizures, or hypoxic-ischemic encephalopathy), necrotizing enterocolitis, or death. Composite adverse outcome was ≥1 of the aforementioned complications., Results: Overall, 3001 singleton cesarean deliveries were included. The rate of abnormal umbilical cord gas studies with the use of definitions A-E was 2.6%, 0.3%, 1.2%, 0.3%, and 0.1%, respectively. The overall rate of adverse neonatal outcome for the entire cohort was 14.43% (433/3001). There was no correlation between abnormal umbilical cord gas studies and composite adverse neonatal outcome with the use of any of the definitions A-E (P=.2, P=.3, P=.2, P=.3, P=.1, respectively). The sensitivity and specificity of abnormal umbilical cord gas studies as a predictor of composite adverse neonatal outcome were calculated for each of the abnormal umbilical cord gas studies definitions; although the sensitivity was extremely low (0-2.07%), the specificity was high (97.2-99.9%) CONCLUSION: Abnormal umbilical cord gas studies are an uncommon finding in cases of singleton term singleton cesarean deliveries and do not correlate with adverse neonatal outcomes. Therefore, the clinical usefulness and cost-effectiveness of obtaining these studies routinely should be questioned., (Copyright © 2019 Elsevier Inc. All rights reserved.)

We conducted a 5-year retrospective cohort study on women undergoing caesarean section to investigate factors influencing the operating room-to-incision interval. Time-to-event analysis was performed for category-1 caesarean section using a Cox proportional hazards regression model. Covariates included: anaesthetic technique; body mass index; age; parity; time of delivery; and gestational age. Binary logistic regression was performed for 5-min Apgar score ≥ 7. There were 677 women who underwent category-1 caesarean section and who met the entry criteria. Unadjusted median (IQR [range]) operating room-to-incision intervals were: epidural top-up 11 (7-17 [0-87]) min; general anaesthesia 6 (4-11 [0-69]) min; spinal 13 (10-20 [0-83]) min; and combined spinal-epidural 24 (13-35 [0-75]) min. Cox regression showed general anaesthesia to be the most rapid method with a hazard ratio (95%CI) of 1.97 (1.60-2.44; p < 0.0001), followed by epidural top-up (reference group), spinal anaesthesia 0.79 (0.65-0.96; p = 0.02) and combined spinal-epidural 0.48 (0.35-0.67; p < 0.0001). Underweight and overweight body mass indexes were associated with longer operating room-to-incision intervals. General anaesthesia was associated with fewer 5-min Apgar scores ≥ 7 with an odds ratio (95%CI) of 0.28 (0.11-0.68; p < 0.01). There was no difference in neonatal outcomes between the first and fifth quintiles for operating room-to-incision intervals. General anaesthesia is associated with the most rapid operating room-to-incision interval for category-1 caesarean section, but is also associated with worse short term neonatal outcomes. Longer operating room-to-incision intervals were not associated with worse neonatal outcomes., (© 2018 The Association of Anaesthetists of Great Britain and Ireland.)

Objective: To investigate the relationship between the five-minute Apgar score categories (low, intermediate, and normal), mode of birth and neonatal outcomes., Methods: This was a retrospective cross sectional study of term singleton deliveries at Mater Mothers' Hospital in Brisbane, Australia between January 2007 and December 2015. The five minute score was subdivided in to three categories - low (0-3), intermediate (4-6), and normal (≥7). These were correlated with adverse neonatal outcomes and mode of birth. The referent cohort was the normal Apgar group., Results: The study cohort consisted of 39,258 births with a recorded five minute Apgar score. Of these, 38,705 (98.6%) neonates had a normal (≥7) Apgar score, 439 (1.1%) had an intermediate score (4-6) and 114 (0.3%) had a low (0-3) score. Neonatal complications including respiratory distress, feeding problems, hypothermia, and seizures were all significantly associated with both low and intermediate Apgar scores. Emergency operative birth (caesarean and instrumental) conveyed a higher risk of low and intermediate scores and poorer neonatal outcomes., Conclusions: Low and intermediate five minute Apgar scores were strongly associated with mode of birth and poorer neonatal outcomes.

Purpose: To stratify maternal and neonatal outcomes of trials of labor after previous cesarean delivery (TOLAC) by gestational age., Methods: Retrospective cohort study of all singleton pregnancies with one previous cesarean delivery in TOLAC at term between 2007 and 2014. We compared outcomes of delivery at an index gestational week, with outcomes of women who remained undelivered at this index gestational week (ongoing pregnancy). Odds ratios and 95% confidence intervals were adjusted for maternal age, previous vaginal delivery, induction of labor, epidural use, presence of meconium, and birth weight > 4000 g., Results: Overall, 2849 women were eligible for analysis. Of those, 2584 (90.7%) had a successful TOLAC and 16 women (0.56%) had uterine rupture. Those rates did not differ significantly for any gestational age (GA) group. Following adjustment for possible confounders, GA was not found to be independently associated with adverse maternal or neonatal outcomes., Conclusion: Among women at term with a single previous cesarean delivery, GA at delivery was not found to be an independent risk factor for TOLAC success or uterine rupture. We suggest that GA by itself will not serve as an argument for or against TOLAC.

Purpose: To assess the effect of advanced maternal age on the obstetrics and neonatal outcome of twin pregnancies., Methods: A retrospective study of 716 dichorionic-diamniotic twin pregnancies delivered at our institute. The study population was divided into two groups: women aged 35-39 years (group A, n = 142) and women aged ≥ 40 years (Group B, n = 48). The control group consisted of women younger than 35 years (group C, n = 516)., Results: The rate of cesarean section (CS) was significantly higher among women older than 35 years compared to the control group (A 76.8% and B 87.5% vs C 65.7%, P = 0.001). Women older than 35 years were also at higher risk for developing hypertensive disorders (A 7.0%, B 14.6%, vs C 5.4%, P = 0.04). On multivariate regression analysis, maternal age was found to be independently associated with a higher rate of CS (odds ratio vs reference group C: group A 1.6, 95% CI 1.08-2.6; group B 3.2, 95% CI 1.3-7.8). There was no difference between the groups in the rate of neonatal complications., Conclusion: Women with twin pregnancy, older than 35 years, have a significantly higher rate of CS and hypertensive disorder. This rate increases with maternal age, with no increased rate of neonatal complications.

Background: The dramatic rise in cesarean delivery rates worldwide in recent decades, without evidence of a concomitant decrease in cerebral palsy rates, has raised concerns about its potential negative consequences for maternal and infant health. In 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine jointly published an Obstetric Care Consensus for safe prevention of the primary cesarean delivery., Objective: We sought to assess whether modification of our protocol to implement these recommendations helped to decrease our primary cesarean delivery rate safely., Study Design: This is a before-and-after retrospective cohort study at a university referral hospital. In March 2014, the threshold for defining active labor changed from 4 to >6 cm and arrest of first-stage labor from lack of cervical change despite regular contractions after 3 hours of oxytocin administration with amniotomy and epidural anesthesia to no change after 4 hours of adequate or 6 hours of inadequate contractions in women with an epidural. The definition of second-stage arrest of labor changed simultaneously from lack of progress for 3 hours with adequate contractions in women with epidural anesthesia to no progress for ≥4 hours in nulliparas or 3 hours in multiparas with an epidural. We compared maternal and neonatal outcomes over two 1 year periods: from March 2013 to February 2014 (before, preguideline) and from June 2014 to May 2015 (after, postguideline). We included all women with singleton pregnancies at ≥37 weeks' gestation, in vertex presentation, in spontaneous or induced labor, and with epidural anesthesia. We excluded women with an elective or previous cesarean delivery and those with obstetric or fetal complications., Results: This study included 3283 and 3068 women in the before and after periods, respectively. The groups had similar general and obstetric characteristics. The global cesarean delivery rate decreased significantly from 9.4% in the preguideline to 6.9% in the postguideline period (odds ratio, 0.71; 95% confidence interval, 0.59-0.85; P < .01). The cesarean delivery rate for arrest of first-stage labor fell by half, from 1.8% to 0.9% (odds ratio, 0.51; 95% confidence interval, 0.31-0.81; P < .01) but was significant only among nulliparous women. The cesarean delivery rate for second-stage arrest of labor decreased but not significantly between periods (1.3% vs 1.0%; odds ratio, 0.73; 95% confidence interval, 0.44-1.22; P = .2), and the cesarean delivery rate for failure of induction remained similar (3.7% vs 3.5%; odds ratio, 1.06; 95% confidence interval, 0.06-13.24; P = .88). The median duration of labor before cesarean delivery also became significantly longer among nulliparous women during the later period. Maternal and neonatal outcomes did not differ between the 2 periods, except that the rate of 1 minute Apgar score <7 fell significantly in the later period (8.4% vs 6.9%; odds ratio, 0.80; 95% confidence interval, 0.66-0.97; P = .02)., Conclusion: The modification of our protocol by implementing the new consensus recommendations was associated with a reduction of the rate of primary cesarean delivery performed for arrest of labor with no apparent increase in immediate adverse neonatal outcomes in nulliparous women at term with singleton pregnancies in vertex presentation and with epidural anesthesia. Further studies are needed to assess the long-term maternal and neonatal safety of these policies., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The objective of this study was to assess the risk of emergency cesarean deliveries (CDs) and adverse neonatal/maternal outcomes according to the planned gestational age at delivery (GAD) for elective CD., Methods: The study population consisted of term singleton pregnant women who were booked for elective CD and were subsequently delivered at term by CD, after excluding cases with a trial of labor. The relationship between the planned GAD, risk of emergency CD prior to planned date, and adverse neonatal/maternal outcomes were determined., Results: The frequency of emergency CD, adverse neonatal and maternal outcomes were 9.5%, 4.5%, and 5.9%, respectively. The risk of emergency CD prior to the planned delivery date increased significantly according to the planned GAD (5.8% at 37 weeks, 8.2% at 38 weeks, 13.6% at 39 weeks, and 26.7% at 40 weeks or more of planned GAD, P = 0.005). Emergency CD was associated with an increased risk of adverse maternal outcomes, whereas the risk of adverse neonatal outcomes did not differ. In the total study population including both cases with elective and emergency CD, the risk of adverse maternal outcomes did not increase according to the planned GAD, and the risk of adverse neonatal outcomes decreased significantly according to the planned GAD., Conclusion: The risk of emergency CD increased as the planned GAD increased, but the risk of adverse maternal outcomes did not increase and the risk of adverse neonatal outcomes decreased significantly according to the planned GAD in the total study population including elective/emergency CD., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2018 The Korean Academy of Medical Sciences.)

Background: The relation between grand multiparity (GMP) and the possible adverse pregnancy outcomes is not well identified. GMP (parity ≥5 births) frequently occurs in the Arab nations; therefore, this study aimed to identify the correlation between GMP and the different adverse maternal and neonatal outcomes in the Saudi population., Method: This cohort study was conducted on a total of 3327 women from the labour ward in King Khaled University Hospital, Riyadh, Saudi Arabia. Primiparous, multiparous and grand multiparous females were included. Socio-demographic data and pregnancy complications like gestational diabetes or hypertension, preeclampsia and intrauterine growth restriction were retrieved from the participants' files. In addition, the labour ward records were used to extract information about delivery events (e.g. spontaneous preterm delivery, caesarean section [CS]) and neonatal outcomes including anthropometric measurements, APGAR score and neonatal admission to the intensive care., Results: Primiparas responses were more frequent in comparison to multiparas and GMP (56.8% and 33%, and 10.2% respectively). In general, history of miscarriage was elevated (27.2%), and was significantly higher in GMP (58.3%, p < 0.01). Caesarean delivery was also elevated (19.5%) and was significantly high in the GMP subgroup (p < 0.01). However, after adjustment for age, GMP were less likely to deliver by CS (odds ratio: 0.6, 95% CI: 0.4-0.8; p < 0.01). The two most frequent pregnancy-associated complications were gestational diabetes and spontaneous preterm delivery (12.6% and 9.1%, respectively). The former was significantly more frequent in the GMP (p < 0.01). The main neonatal complication was low birth weight (10.7%); nevertheless, neonatal admission to ICU was significantly higher in GMP (p = 0.04), and low birth weight was more common in primiparas (p < 0.01). Furthermore, logistic regression analysis revealed an insignificant increase in the maternal or neonatal risks in GMP compared to multiparas after adjustment for age., Conclusion: Grand multiparous Saudi females have similar risks of maternal and neonatal complications compared to the other parity groups. Advanced age might play a major role on pregnancy outcomes in GMP. Nevertheless, grand multiparty might not be discouraged as long as women are provided with good perinatal care.

Background: The optimal mode of delivery as a predictor for outcomes in preterm infants is under debate. The purpose of this study was to evaluate the effect of the delivery mode on neonatal outcome among preterm infants in different birthweight categories., Methods: A retrospective analysis of singleton preterm deliveries from 23 + 0 to 33 + 6 gestational weeks was performed. Infants were categorized based on birthweight as large for gestational age (LGA), appropriate for gestational age (AGA) and small for gestational age (SGA). The Apgar score at 5 min served as the main outcome parameter. A sensitivity analysis was performed to adjust for maternal age, parity and fetal malformations as potential confounders., Results: Out of 1320 singleton preterm infants, 970 (73.5%) were delivered by cesarean section and 350 (26.5%) were delivered vaginally. The AGA infants between 23 + 0 and 27 + 6 weeks showed better outcomes after cesarean section (p < 0.01 from 23 + 0-24 + 6; p = 0.03 from 25 + 0-27 + 6), whereas AGA infants between 31 + 0 and 33 + 6 gestational weeks showed better outcomes after vaginal delivery (p = 0.02). Cesarean section was beneficial in extremely and very preterm SGA infants (p = 0.01 from 25 + 0-27 + 6; p = 0.02 from 28 + 0-30 + 6). The sensitivity analysis showed no confounding effect of other variables., Conclusion: There is a benefit from cesarean section in AGA preterm infants until 28 weeks of gestation and in SGA preterm infants until 31 weeks of gestation. Vaginal delivery should be chosen for moderately preterm AGA infants.

Objectives: Caesarean section is associated with increased maternal morbidity compared to a vaginal delivery, especially if it occurs during labour. Little data on caesarean section performed at full dilatation is available., Methods: This was a retrospective study done in University Hospital of type 3 over a period of ten years, including future primiparous patients who had a caesarean section performed at full dilatation, compared to a control group of patients whose caesarean section was conducted in first part of the labour. We collected different maternal data per- and postoperative and neonatal., Results: In total, 824 patients were enrolled including 412 in each group. For caesarean section at full dilatation, foetal extraction required more manoeuvres (RR=3.05; 95% CI: 2.1; 4.39; P<0.001); we noted more extension of hysterotomy (RR=1.79; 95% CI: 1.30; 2.46; P<0.001). Postoperative and neonatal maternal morbidity was not different, except more frequent neonatal trauma for caesarean section at full dilatation., Conclusion: A caesarean section at full dilatation has an excess intraoperative risk and requires great caution. Nevertheless, no significant increase of postoperative and neonatal complications can be proved., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Objective: Women with diabetes may need elective preterm delivery due to pregnancy or diabetes related complications. The aim of this study was to describe the neonatal outcomes arising from elective preterm delivery in diabetic women., Method: Suitable patients were identified by the obstetric team at Hull Royal Infirmary Women and Children's Hospital and data was extracted from their case notes. 45 diabetic women with planned preterm delivery were identified within a set time frame, resulting in 48 babies., Results: Of the 48 babies born, 47 survived. 36 out of 48 were delivered via caesarean section. Gestational ages ranged from 29+3 to 36+6 weeks, and 24 out of 48 (50%) had a birth weight greater than the 90th centile for gestational age.34 out of the 48 babies experienced some form of neonatal complication and were admitted to the neonatal unit. The median duration of stay in the neonatal unit was 7 days. 14 of the surviving neonates suffered from respiratory distress, although only 4 required surfactant therapy to regain respiratory function. However, the incidence of serious neonatal complications in those born after 34 weeks was shown to be low., Conclusions: Elective preterm delivery after 34 weeks had little effect on overall neonatal outcome. Therefore it could be proposed that elective preterm delivery after 34 weeks gestation may be an acceptable option in diabetic women if there are maternal or obstetric complications.

Objective: This study is aiming to determine an actual incidence and characteristics of complications in cesarean section for severe pre-eclampsia (PE) by analysis of a large cohort from a single tertiary care center according to two choices of anesthesia., Methods: Electronic medical records of pregnant women complicated with severe PE delivered by cesarean section from January 2002 to December 2011 were retrospectively reviewed. Medical records of their corresponding neonates were also identified and reviewed., Results: A total of 701 women and 740 neonates (28 twin pairs) were identified. Anesthetic techniques were spinal anesthesia (SA) (88%) and general anesthesia (GA) (12%). Total maternal and neonatal deaths were 0.3% and 1.2%, respectively. Patients in GA group had a higher incidence of coagulopathy, immediate postpartum hemorrhage, intensive care unit admission, renal failure, respiratory complications, and death (p < 0.05). Neonates born from women in GA group had a higher incidence of lower birth weight, birth asphyxia, prematurity, neonatal intensive care admission, respiratory complications, and death (p < 0.05)., Conclusion: Spinal anesthesia can be safely administered to severely pre-eclamptic parturients undergoing cesarean section. General anesthesia is associated with more untoward outcomes, as it has been chosen in patients with more severity of the disease.

Objective: The objective of this study is to evaluate maternal and neonatal outcomes associated with trial of labor after cesarean (TOLAC) in women with three prior cesarean delivery (CD) and at least one prior vaginal delivery., Methods: This is a retrospective study using data collected from clinical records of women three prior CD and at least one prior vaginal delivery who were referred to our unit. Maternal and perinatal outcomes were compared between women with three prior CD who underwent TOLAC and those who underwent planned repeated CD (i.e. control group). The primary outcome was a composite of maternal complications including at least one of the followings: need for blood transfusion, uterine rupture, hysterectomy, and admission to intensive care unit., Results: Fifty singleton gestations with three prior CD at with at least one prior vaginal birth were analyzed. Of them, 10 accepted to undergo TOLAC. Of the 10 women who underwent TOLAC, nine had vaginal birth and one had CD for non-reassuring pattern. We found no significant differences in the primary outcome, in need for blood transfusion, in the incidence of uterine rupture, hysterectomy, and admission to intensive care unit comparing TOLAC group with controls., Conclusion: TOLAC in women with three prior CD and at least one prior vaginal delivery is a viable option and is not associated with higher risk of adverse maternal or fetal outcomes.

Objective: The objective of this study is to correlate between pregnancy outcome and placental pathology in emergent cesarean deliveries (ECD) for non-reassuring-fetal-heart-rate (NRFHR) performed in women in their active phase of labor versus those performed in non-laboring women., Methods: A retrospective cohort study. Data were reviewed for all pregnancies necessitating ECD for NRFHR between January 2009 and December 2013. Maternal outcome, neonatal outcome, and placental pathology parameters were compared between ECDs performed during active phase of labor and those performed before the active phase of labor (non-labor group)., Results: During the study period, a total of 661 ECDs were performed due to NRFHR. Compared with the active labor group (n = 335), the non-labor group (n = 326) had more pre-eclampsia (p = 0.033), small for gestational age (SGA) (p = 0.016), and preterm labor (p < 0.001). Worse composite neonatal outcome was observed in the non-labor group compared with the active labor group, p < 0.001. By a stepwise logistic regression model, non-labor was independently associated with adverse neonatal outcome (1.88 OR CI; 1.19-2.96, p = 0.007). Placental inflammatory lesions were more common in the active labor group (p= 0.043), and abnormal cord insertions were more common in the non-labor group (p = 0.002) as well as placental weight <10th% (p = 0.019)., Conclusion: Higher rate of pregnancy complications, abnormal cord insertion, smaller placentas, and worse neonatal outcome are associated with ECD for NRFHR when performed before the phase of active labor.

Purpose: To clarify whether an increased cesarean section rate improves the short-term neonatal outcome in singleton term pregnancies with cephalic presentation., Methods: A retrospective study of institutional data on the mode of delivery and neonatal outcome. The study included two cohorts: 1998-1999 (n = 7437) and 2004-2005 (n = 8505), since the institutional cesarean section rate increased sharply between these cohorts and has remained stable after the latter study period., Results: The caesarean section rate almost doubled from 6.8 to 11.3 % (p < 0.001), during the study period. The rate of neonates suffering severe birth asphyxia remained low in both cohorts (0.4 vs. 0.6 %) and there were no significant differences in neonatal outcome (Apgar score <4 at 1 min and Apgar score <7 at 5 min, severe birth asphyxia, resuscitation or artificial ventilation) between the study periods. In the subgroup of neonates delivered vaginally, no significant differences were found in the above-mentioned neonatal outcomes between the cohorts. Apart from other outcomes admissions to neonatal intensive care unit increased significantly (p < 0.001) during the latter period (0.8 vs 1.6 %)., Conclusions: Increasing cesarean section rate from a low to a moderate does not improve the short-term neonatal outcome in term singleton pregnancies. On the contrary neonatal intensive care unit admissions increased with increasing caesarean section rate. Furthermore it is possible to achieve good neonatal outcome with a low cesarean section rate.

Aim: The aim of the study was to examine maternal age, parity, and estimated neonatal birth weight (BW) depending on the mode of a full-term breech presentation (BP) birth delivery and neonatal outcomes., Material and Methods: One hundred and forty-six singleton term breech presentation pregnancies were included in a retrospective study conducted at the Department of Gynecology/Obstetrics, Clinical Center of Serbia in Belgrade in 2013. Statistical analysis: Student's-t test, χ(2) likelihood ratio, and the Fisher's exact test. The level of statistical significance was set at p <0.05., Results: An ECS was the most common mode of delivery in (81.2%) nulliparous older than 35 years and most of the neonates (66.67%) with an estimated birth weight (BW) above 3500 grams were delivered by elective cesarean section (ECS). Perinatal asphyxia remained increased in the successful vaginal delivery (SVD) group (23.8%) compared with the urgent CS (UCS) group (13.3%) (p = 0.035). Birth asphyxia was the most common in neonates were delivered by SVD (23.8%). There were no cases of perinatal deaths., Conclusion: ECS remained the recommended mode of breech term delivery in nulliparous women older than 35 years, as well as in neonates with an estimated BW above 3500 grams.

Objective: To compare the incidence of postpartum maternal and neonatal complications and hospital readmission in patients discharged 24 versus 72 h after cesarean section., Methods: Using randomization, 1495 patients were discharged after 24 h and 1503 patients were discharged after 72 h. All patients fulfilled the discharge criteria. Patients were assessed 6 weeks after delivery, any maternal or neonatal problems or hospital readmissions during this time interval were reported., Results: There was no difference in maternal hospital readmission between the two groups, but there was a significantly higher neonatal readmission rate in the 24-h group mainly due to neonatal jaundice. As for the complications reported after 6 weeks, the only two significant outcomes were initiating breast feeding, being significantly higher in the 72-h group [OR and 95% CI 0.77 (0.66-0.89)] and the mood swings being significantly lower in the 72-h group [OR and 95% CI 2.28 (1.94-2.68)]., Conclusion: Our recommendation is still in favor of late discharge, after cesarean delivery. Bearing in mind, that an early 24-h discharge, after cesarean delivery is feasible, but with special care of the neonate, with early visit to the pediatrician and early establishment of effective lactation.

Background: Evidence about optimal mode of delivery for preterm birth is lacking, and there is thought to be considerable variation in practice., Objective: To assess whether variation in hospital preterm caesarean section rates (Robson Classification Group 10) and outcomes are explained by casemix, labour or hospital characteristics., Materials and Methods: Population-based cohort study in NSW, 2007-2011. Births were categorised according to degree of prematurity and hospital service capability: 26-31, 32-33 and 34-36 weeks' gestation. Hospital preterm caesarean rates were investigated using multilevel logistic regression models, progressively adjusting for casemix, labour and hospital factors. The association between hospital caesarean rates, and severe maternal and neonatal morbidity rates was assessed., Results: At 26-31 weeks' gestation, the caesarean rate was 55.2% (seven hospitals, range 43.4-58.4%); 50.9% at 32-33 weeks (12 hospitals, 43.4-58.1%); and 36.4% at 34-36 weeks (51 hospitals, 17.4-48.3%). At 26-31 weeks and 32-33 weeks' gestation, 81% and 59% of the variation between hospitals was explained with no hospital significantly different from the state average after adjustment. At 34-36 weeks' gestation, although 59% of the variation was explained, substantial unexplained variation persisted. Hospital caesarean rates were not associated with severe maternal morbidity rates at any gestational age. At 26-31 weeks' gestation, medium and high caesarean rates were associated with higher severe neonatal morbidity rates, but there was no evidence of this association ≥32 weeks., Conclusion: Both casemix and practice differences contributed to the variation in hospital caesarean rates. Low preterm caesarean rates were not associated with worse outcomes., (© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Objective: To explore the variation in hospital caesarean section (CS) rates for nulliparous women, to determine whether different case-mix, labour and delivery, and hospital factors can explain this variation and to examine the association between hospital CS rates and outcomes., Design: Population-based cohort study., Setting: New South Wales, 2009-2010., Population: Nulliparous women with singleton cephalic live births at term., Methods: Random effect multilevel logistic regression models using linked hospital discharge and birth data., Main Outcome Measures: Prelabour and intrapartum CS rates following spontaneous labour or labour induction; maternal and neonatal severe morbidity rates., Results: Of 67 239 nulliparous women, 4902 (7.3%) had a prelabour CS, 39 049 (58.1%) laboured spontaneously, and 23 288 (34.6%) had labour induced. Overall, there were 18 875 (28.1%) CSs, with labour inductions twice as likely to result in an intrapartum CS compared with women with a spontaneous onset of labour (34.0% versus 15.5%). After adjusting for differences in case-mix, labour and delivery, and hospital factors, the overall variation in CS rates decreased by 78% for prelabour CSs, 52% for intrapartum CSs following spontaneous labour and 9% following labour induction. Adjusting for labour and delivery practices increased the unexplained variation in intrapartum CSs. The adjusted rates of severe maternal and neonatal morbidity were not significantly different across CS rate quintile groups, except for women in spontaneous labour, where the hospitals in the lowest CS quintile had the lowest neonatal morbidity rate., Conclusions: Differences in clinical practice were substantial contributors to variation in intrapartum CS rates. Our findings suggest that CS rates in some hospitals could be lowered without adversely affect pregnancy outcomes., (© 2015 Royal College of Obstetricians and Gynaecologists.)

Objective: To correlate between intraoperative findings, placental histopathology and neonatal outcome in emergent cesarean deliveries (ECD) for non-reassuring fetal heart rate (NRFHR)., Study Design: Data on ECD for NRFHR were reviewed for labor, documented intraoperative findings, neonatal outcome parameters and placental histopathology reports. Results were compared between those with and without intraoperative findings. Placental lesions were classified to those related to maternal underperfusion or fetal thrombo-occlusive disease, and those related to maternal (MIR) and fetal (FIR) inflammatory responses. Neonatal outcome consisted of low Apgar score (≤7 at 5 min), cord blood pH<7.0, and evidence of respiratory distress, necrotizing enterocolitis, sepsis, transfusion, ventilation, seizure, hypoxic-ischemic encephalopathy, phototherapy, or death., Results: Intraoperative findings were observed in 49.5% of 543 women, mostly cord complications (77%). Placental lesions were more common in those without intraoperative findings as compared to those with intraoperative findings: placental lesions related to maternal under-perfusion, vascular lesions, 9.1% vs. 4.1%, p=0.024, and villous changes, 39.2% vs. 30.7%, p=0.047, lesions consistent with fetal thrombo-occlusive disease, 13.6% vs. 7.4%, p=0.024, and inflammatory lesions, MIR and FIR, p=0.033, p=0.001, respectively. By using multivariate logistic regression analysis, adverse neonatal outcome was found to be dependent on maternal age, gestational age, preeclampsia placental weight <10th%, and MIR., Conclusion: NRFHR necessitating ECD may originate from different underlying mechanisms. In about half, the insult is probably acute and can be identified intraoperatively. In the remaining half, underlying placental compromise may be involved., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)